Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 43 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
26D
8E
6F
Potential for minimal harm
0A
0B
1C
February 10, 2026Standard inspection, Complaint inspection · 13 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(D)Based on record review and interview; the facility failed to ensure sufficient staffing to ensure call lights were answered in a timely manner. This had the potential to affect all facility residents who utilized a call device. This had the potential to effect all residents in the building. The facility census was 28.
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(D)Based on record review and interview; the facility failed to ensure 8 hours of consecutive Registered Nurse (RN) coverage in a 24-hour period 7 days per week as required. This had the potential to affect all facility residents. The facility census was 28.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(I)Based on record review and interview; the facility failed to implement their Quality Assessment and Performance Improvement (QAPI) plan to maintain a system to prevent repeat deficient practices including accidents, weight loss, sufficient staffing, unnecessary medications and Emergency Preparedness. This had the potential to affect all facility residents. The facility census was 28.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observation, record review, and interview; the facility failed to prevent the potential for cross contamination as the staff failed to utilize the required Personal Protective Equipment (PPE-items such as gowns, gloves, masks, goggles, face shields, and foot coverings) when performing personal/catheter cares for Resident 7 who was on Enhanced Barrier Precautions (EBP-use of PPE to reduce the transmission of multi drug-resistant organisms (MDRO- organisms resistant to at least one or more classes of antimicrobial agents) between residents) and to ensure ongoing surveillance of infections. The total sample size was 20 and the facility census was 28.
- E
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(D)(E)Based on record review and interviews; the facility failed to obtain informed consent for the use of psychotropic medications and/or information for alternate treatment options for Residents 3, 6, 24, and 30. The sample size was 5 and the facility census was 28.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(S) Based on observations, record review, and interviews; the failed to ensure Resident 7 was treated with respect and dignity during the provision of personal cares. The sample size was 1 and the facility census was 28.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(G) Based on record review and interview; the facility failed to ensure Resident's 6's medication regimen was free from unnecessary medications due to failure to monitor for potential side effects of a psychotropic medication. The sample size was 5 and the facility census was 28.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteLicensure reference: 175 NAC 12-006.02(H)Based on record review and interview: the facility failed to report an allegation of potential staff to resident abuse and to send the results of an investigation to the State Agency within the required timeframes for Resident 7. The sample size was 2 and the facility census was 28.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(A)Based on record review and interview; the facility failed to notify the Ombudsman of facility discharges for Residents 1 and 34. The sample size was 2 and the facility census was 28.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(iii) Based on interview and record review; the facility failed to address Resident 28's nutritional status and risk for weight loss on the resident's comprehensive plan of care and failed to involve Resident 12's legal guardian in the development of the resident's care plan. The total sample size was 20 and the facility census was 28.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)(i)(3) Based on record review and interview; the facility failed to revise current fall interventions and/or develop new interventions to prevent ongoing falls for Resident 6. The sample size was 6 and the facility census was 28.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09(J)(i)(1)Based on record review and interview; the facility failed to implement nutritional interventions to address a weight loss for 1 (Resident 28) of 2 sampled residents. The facility census was 28.
- C
Post nurse staffing information every day.
Inspectors wroteLicensure Reference Number 175 NAC 12-006Based on record review and interview; the facility failed to ensure the daily staff posting had the required information. This had the potential to affect all facility residents. The facility census was 28.
November 20, 2025Complaint inspection · 1 citation
- E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record reviews and interviews; the facility failed to notify Resident 1's practitioner of the residents increased lethargy, decreased appetite, lowered blood glucose levels and staff failure to administer insulin; and Resident 3 and 4's practitioner and/or responsible parties of ongoing falls. The sample size was 5 and the facility census was 33. A. Review of the facility policy Notification of Change with a revision date of 12/23/2024 revealed the purpose of the policy was to identify when regulation required notifications to occur. [...]
April 22, 2025Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report an injury of unknown origin and to submit an investigation to the State Agency within 5 working days for 1 (Resident 3) of 5 sampled residents. The facility identified a census of 31.
- D
Respond appropriately to all alleged violations.
Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to thoroughly investigate allegations of potential abuse for Residents 1 and 2 and to report an allegation of potential abuse for Resident 2 within the required timeframe. The sample size was 5 and the facility census was 31.
January 15, 2025Standard inspection, Complaint inspection · 7 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteC. Review of Resident 16's MDS dated [DATE] revealed the resident was cognitively impaired, had Diabetes, had a dementia diagnosis, and received substantial assistance with bathing. Review of Resident 16's Care Plan with a revision date of 12/27/24 revealed the resident had impaired cognitive function and confusion, self-care deficits and requested one bath weekly and needed staff assistance to bathe. Review of Resident 16's Bathing Records from December 1st, 2024, through January 15th, 2025, revealed the following: -Bathing occurred on the following days in December 2024: December 4th, 11th, and 18th. -Bathing occurred on the following days in January 2025: No documented baths as of January 2025. -There was no evidence of bathing from December 18th, 2024, and January 15th, 2025 (28 days). [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on observation, record review and interview; the facility failed to meet the Activities of Daily Living (ADL) needs for Resident 20 and the bathing needs for Resident's 3, 11, 16 and 24. The sample size was 20 with a census of 31.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D7 Based on record review and interviews; the facility failed to develop new interventions and/or revise current interventions to prevent ongoing falls for Residents 182 and 26. The sample size was 4 and the facility census was 31.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on record review and interviews; the facility failed to revise nutritional interventions and/or develop new interventions to address ongoing weight loss for 1 (Resident 14) of 2 sampled residents. The facility census was 31.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(A) Based on record review and interview; the facility failed to ensure a documented rationale for the use of an anti-depressant for Resident 4. The sample size was 5 and the facility census was 31.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observation, record review, and interview, the facility failed to implement hand hygiene at appropriate intervals and utilize Personal Protective Equipment (PPE) in a manner to prevent the potential spread of infection for Resident 15. The sample size was 16 and the facility census was 31.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(A) Based on record review and interview; the facility failed to offer Resident 16 the recommended Pneumococcal vaccines in accordance with facility policy and Center for Disease Control (CDC) guidelines. The sample size was 5 and the facility census was 31.
September 25, 2024Complaint inspection · 7 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04 Based on observation, record review, and interview; the facility failed to have staff adequate to meet the bathing needs of residents, respond in a timely fashion to call lights and to meet the housekeeping needs of residents. The sample size was 6 and the facility census was 33.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.19 Based on observation, record review and interview; the facility failed to maintain the cleanliness of the resident's rooms and bathrooms and to maintain a safe and odor free environment. This affected 12 (rooms 98, 99, 103, 104, 105, 106, 205, 300, 301, 305, 306 and 309) out of 33 resident rooms. The facility census was 33.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) (i)(1) Based on interview and record review, the facility failed to provide bathing assistance for 4 (Residents 1, 2, 4, and 5) of 6 sampled residents who were dependent with bathing. The facility census was 33.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(4) Based on observation, record review, and interview; the facility failed to ensure 1 (Resident 3) of 6 sampled residents call light was accessible. The facility census was 33. A. Review of the facility policy Call Light with a revision date of 7/29/24 revealed the facility ensured residents always had a method for calling for assistance and prompt answering of call lights. Review of Resident 3's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 9/16/24 revealed the resident was admitted to the facility on [DATE], was dependent for dressing, all hygiene, bathing, and transfers. The resident's urinary continence was not rated due to the presence of a catheter. [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i) Based on record review and interview; the facility failed to ensure the resident's family or responsible party were notified of orders, appointments, and/or procedures for 1 (Resident 1) of 5 sampled residents. The facility census was 33.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv)(1) Based on observation, record review and interview; the facility failed to ensure potential infection/complication with Resident 3's urinary catheter (tube used to drain urine from the bladder and collected in a sterile closed system drainage bag). The sample size was 3 and the facility census was 33.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on record review and interview; the facility failed to implement an ongoing system for tracking antibiotic use to identify trends in infections for 1 (Resident 1) of 4 sampled residents. The facility census was 33.
January 10, 2024Standard inspection, Complaint inspection · 13 citations
- G
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility failed to notify Resident 22's physician, Resident 29's responsible party and physician, and Resident 2's responsible party of a change in condition. The sample size was 3 residents. The facility census was 33.
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D8b Based on observation, interview, and record review; the facility failed to identify and implement measures to prevent a significant weight loss and notify the provider for 1 (Resident 29) of 3 residents sampled. The facility census was 33.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteD. Review of a facility investigation report dated 12/4/23 related to a fall incident for Resident 5 revealed the following: -12/3/23 at 5:45 AM, staff were assisting the resident to the bathroom. The resident stood from the toilet to transfer into the wheelchair, the resident's knee buckled, and staff then lowered the resident to the floor. -12/3/23 at 7:30 AM the resident complained of left knee pain and had increased swelling to the knee. -12/3/23 at 1:30 PM the resident continued to complaint of left lower leg pain and was unable to bear weight on the leg. -12/4/23 at 10:00 AM the resident's knee was swollen, and the resident was unable to bend the left knee. The physician was notified, and the resident was sent for an x-ray. The resident was admitted to the hospital with a fracture of the femur, fibula and the fifth toe of the left leg/foot. [...]
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to code the Minimum Data Set (MDS-federally mandated assessed used to develop resident care plans) to reflect the resident's status at the time of the assessment regarding nutritional approaches for Residents 10, 2, 84, and 16 and medication use for Resident 17. The sample size was 17 and the facility census was 33.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on observations, record review and interviews; the facility failed to: 1) obtain orders for management of a blood glucose monitoring device and to ensure assessments and ongoing monitoring were completed for wound care and blood glucose levels for Resident 184; 2) reposition Resident 16 in accordance with the plan of care to prevent the potential for skin breakdown; and 3) follow physician orders regarding fluid restriction and weight monitoring for Resident 5. The sample size was 3 and the facility census was 33.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(21) Based on observation, interview and record review, the facility failed to ensure Resident 16's dignity was maintained by not putting pants on the resident when staff assisted [gender] to dress for the day. The sample size was 1 and the facility census was 33.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteLicensure Reference Number 175 NAC 12-00605(8) Based on observations, record review and interview; the facility staff failed to evaluate the use of a seatbelt as a restraint for 1 (Resident 84) of 1 sampled resident. The facility staff identified a census of 33.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09A Based on record review and interview; the facility failed to ensure a new PASRR (Pre-admission Screening and Resident Review- a tool used to ensure residents receive the care they require for mental illness) had been completed after a diagnosis of mental illness was identified for 2 (Residents 2 and 29) out of 2 reviewed for PASRR. The facility census was 33.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D2b Based on record review and interview; the facility failed to provide assessment and monitoring of a pressure ulcer to ensure healing for Resident 84. The sample size was 1 and the census was 33.
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04 Based on record review and interviews, the facility failed to ensure sufficient direct care nursing staff were available to answer call lights in a timely manner for Resident 26. The sample size was 17 and the facility census was 33.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications related to long term use of an antibiotic medication for Resident 10. The antibiotic did not specify a duration and had no supporting documentation for clinical use based on laboratory results. The sample size was 1 and the facility census was 33.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure 1 (Resident 16) of 5 sampled residents were free from unnecessary psychotropic (a type of psychoactive medication which alters chemicals in the brain to affect changes in behavior, mood and emotion) medications related to 1) as needed anti-psychotic and anti-anxiety medications without a specified duration, 2) no evidence of ongoing evaluations completed by the physician, and 3) a diagnosis not indicated for an anti-psychotic medication. The facility census was 33.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.17B Based on observation, record review and interview; the facility failed to implement transmission-based precautions to prevent the potential for cross contamination as staff failed to initiate contact precautions for Resident 84 when the resident returned from the hospital with a diagnosis of Methicillin Resistant Staphylococcus Aureus (MRSA-a type of staph infection which is difficult to treat due to resistance to many antibiotics). The total sample size was 17 and the facility census was 33.
Fire safety inspections
25 fire safety citations on file: 2 on February 10, 2026, 16 on January 15, 2025, 7 on January 10, 2024.
Every fire safety citation25 citations
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · February 10, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 10, 2026 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · January 15, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · January 15, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · January 15, 2025 · Corrected (the home has a date of correction)
- D
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
K 925 · January 15, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · January 10, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 10, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 10, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · January 10, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · January 10, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · January 10, 2024 · Corrected (the home has a date of correction)